Changing etiological spectrum and the rise of metabolic risk in liver cancer burden in China (1990–2021) with projections to 2036: a decomposition analysis based on the GBD 2021 study

Liver cancer has long ranked among the leading causes of cancer-related deaths in China. Although hepatitis B virus (HBV) and hepatitis C virus (HCV) were historically the predominant etiologies, their associated disease burden has significantly declined in recent years due to widespread vaccination and antiviral therapies. Concurrently, the burden of liver cancer originating from metabolic dysfunction–associated steatotic liver disease (MASLD), which often progresses to metabolic dysfunction–associated steatohepatitis (MASH), has risen rapidly in association with the growing prevalence of metabolic disorders such as obesity and diabetes. This suggests a structural shift in the etiological landscape of liver cancer in China. Based on data from the Global Burden of Disease Study 2021 (GBD 2021), we systematically analyzed trends from 1990 to 2021 in liver cancer burden attributable to four major causes—HBV, HCV, alcohol consumption, and MASLD—in the Chinese population. Key metrics included ASPR and disability-adjusted life years (DALYs). We further assessed DALY changes attributable to four key risk factors: high body mass index (BMI), high fasting plasma glucose (FPG), alcohol consumption, and tobacco use. Future trends from 2022 to 2036 were projected using a Bayesian age-period-cohort (BAPC) model. From 1990 to 2021, the ASPR for HBV-related liver cancer declined significantly (estimated annual percentage change [EAPC] = − 0.15, 95% uncertainty interval [UI]: − 0.41 to − 0.09), as did that for HCV-related liver cancer (EAPC = − 0.15, 95% UI: − 0.26 to − 0.03). In contrast, alcohol-related liver cancer showed a sustained increase (EAPC = 0.62, 95% UI: 0.43 to 0.81), with MASH-related liver cancer rising at the fastest pace (EAPC = 0.72, 95% UI: 0.53 to 0.91). The burden varied by sex: HBV and HCV-related liver cancer declined more significantly in females, while alcohol- and MASH-related liver cancer increased more markedly in males. Risk-attribution analysis revealed that the proportion of liver cancer DALYs attributable to high BMI rose steadily, with a pronounced increase after 2005. Projections showed that high BMI-attributable DALYs would increase from 7.93% in 2022 to 12.50% in 2036 (+ 57.7%), with a larger rise in males (+ 81.1%). Conversely, FPG-attributable burden was projected to decline by 26.8%. China is undergoing a critical transition in liver cancer prevention, shifting from infectious source control to metabolic risk management. Future strategies should strengthen metabolic screening and early intervention — particularly for high BMI and elevated FPG—while maintaining gains in viral hepatitis control. A precision management system targeting high-risk populations is urgently needed to address the growing challenge of metabolically driven liver cancer.